Physical Activity in Long Term Musculoskeletal Conditions

Original Editor - Caroline Hooper

Top Contributors - Wendy Walker, Kim Jackson, Lucinda hampton, Tony Lowe, Michelle Lee, Simisola Ajeyalemi, Vidya Acharya, Tarina van der Stockt, Rucha Gadgil and Lauren Lopez  

Introduction: Long Term Musculoskeletal Conditions.

In 2015, a study on the Global Burden of Disease and the worldwide impact of all diseases and risk factors included back and neck pain, osteoarthritis and other musculoskeletal disorders in the leading ten causes of adult global age-specific years lived with disability. When discussing disease-specific issues the report stated that “Musculoskeletal disorders continue to be a leading cause of disability worldwide”.  It advised that “a key component of healthy ageing is to maintain mobility, and a key public health intervention recommended for improving health outcomes for all chronic diseases is physical activity”.

ARC MUSCULOSKELETAL HEALTH A public health approach

Arthritis Research UK define musculoskeletal conditions as “disorders of the bones, joints, muscles and spine, as well as rarer autoimmune conditions such as lupus”.  They suggest considering three key categories:

1. The commonest group consists of painful musculoskeletal conditions such as osteoarthritis and back pain. Risk factors include physical inactivity, obesity and injury.
2. Osteoporosis and fragility fractures. ½  women and 1/5  men over the ago of 50 will suffer at least one fragility fracture.
3. Inflammatory conditions such as rheumatoid arthritis.  The conditions in this category are much less common.

In 2013, Arthritis Research UK organized an expert workshop of epidemiologists, public health specialists and others in order to help shape a national agenda for musculoskeletal public health.

A key concept was that musculoskeletal health means more than the absence of a musculoskeletal condition, and that it is possible to have poor musculoskeletal health without having a specific musculoskeletal condition. In order to have good musculoskeletal health the muscles, joints and bones must work well together without pain in order to carry out activities with ease and without discomfort.

At the core of this approach to musculoskeletal health was physical activity. It was emphasized that “remaining active is one of the best things anyone can do for their musculoskeletal health, to help strengthen muscles, keep bones healthy, reduce pain and prolong the life of joints”.  It was recommended that initiatives aimed at increasing physical activity should always explicitly refer to the musculoskeletal health benefits, that joint or back pain is not seen as a barrier to participation, and that these activities are making a difference to people who are living with a musculoskeletal condition.

Recommendations

4 Key recommendations were made:

1. Assessment of Population Health

1When assessing local and national population health, musculoskeletal health must be included in the assessment.

2. Health Programme Design

When designing, implementing and evaluating programmes targeting lifestyle factors such as obesity and physical inactivity, impact on musculoskeletal health should be explicitly included.

3. Health Promotion

When developing health promotion messages, the benefits of physical activity to people with musculoskeletal conditions should be emphasised.

4. Health Data

All this public health activity must be underpinned by high quality data about musculoskeletal health.

Prevention and Management of Musculoskeletal Conditions with Physical Activity

Some specific benefits of physical activity on the musculoskeletal system include increased lean muscle and bone density, strong and supple joints, improved range of joint motion, and improved metabolic rate (Hiwale 2017)

The Arthritis Research Council divide prevention and management of musculoskeletal conditions  into two key areas:  reducing risk (physical activity as primary prevention),  and reducing impact (physical activity as secondary prevention) ( ARC 2013)

Reducing risk: physical activity as primary prevention

Physical activity improves musculoskeletal health. A wide range of physical activities have been shown to be beneficial in reducing overall risk of musculoskeletal pain and disability. These include swimming, walking, cycling and running.( ARC 2013) . An evidence-based Public Health England blog “Preventing Musculoskeletal Disorders has Wider Impacts for Public Health” recommends regular physical activity and exercise at every stage of life (from pregnancy to old-age) to reduce the risk of many musculoskeletal conditions including low back and neck pain, osteoarthritis and falls.

The American College of Sports Medicine has produced several relevant evidence-based position stands relating to physical activity, and the use and prescription of exercise for health. They describe types, and quantity of exercise useful for different components of health. Three position stands are of particular relevance to musculoskeletal health, they include apparently healthy adults, older adults and bone health .  They give precise recommendations for a comprehensive program of exercise including cardiorespiratory, resistance, flexibility, and neuromotor exercise for apparently healthy adults of all ages in order to improve multiple aspects of physical and mental health including musculoskeletal health . Weight bearing endurance activities that involve jumping and resistance exercise that targets all muscle groups are recommended from childhood to older adults in order to improve bone health .  Balance exercises are recommended to help reduce the risk of falls for older adults. The position stands recommend reducing total time spent being sedentary by interspersing short bouts of physical activity and standing , and stipulate that for sedentary people some activity is better than none.  The recommendations on activity and dose are well recognised  and used in International and National  Physical Activity Guidance ( e.g. WHO 2010, Department of Health 2011)

Reducing risk: physical activity as primary prevention

Several studies have examined physical activity and exercise in relation to primary prevention of musculoskeletal problems. Higher levels of fitness may correlate with a lower incidence of musculoskeletal disorders including low back pain in working populations such as the navy and police force.  A dose-response relationship between regular physical activity have been associated with a reduced risk of developing painful osteoarthritis particularly in women.

Additionally, high levels of walking are associated with a reduced need for hip replacement surgery especially for women. Two longitudinal studies indicated that participation in physical activity including running as an adult does not increase the risk of hip osteoarthritis, there doesn’t seem to be a threshold of increasing risk with increased training among walkers and runners. Interestingly running may provide a protective role, and reduce the risk of hip replacement

Biological Mechanisms

A number of biological mechanisms have been demonstrated in studies. These include better nutrition and structure of cartilage, and improved strength of the muscles surrounding joints providing stability. Importantly, physical activity is also important in bone strength, and reducing risk of fragility fracture. Bone strength peaks in mid-adult life, typically between age 40 and 50 years. As in early life, high impact physical activity promotes strengthening of the bones. People who are physically active reach a higher peak bone strength in mid-adult life and reduce the subsequent speed of decline in bone strength.The benefits of this become apparent in later life with reduced risk of fragility fractures ( ARC 2013).

Reducing impact: physical activity as secondary prevention

For people who have already developed a painful musculoskeletal condition, engaging in appropriate physical activity reduces pain intensity, improves quality of life and prevents further disability.( ARC 2013),

A recent high quality systematic review investigated effective options for management of musculoskeletal pain in primary care. It included 10 Cochrane reviews and 3 policy documents, and examined the effects of different exercise modalities on back, neck, shoulder, knee and multi-site pain. The review summarised that “Current evidence shows significant positive effects in favour of exercise on pain, function, quality of life and work related outcomes in the short and long-term for all the musculoskeletal pain presentations (compared to no exercise or other control) but the evidence regarding optimal content or delivery of exercise in each case is inconclusive.” Functional exercises related to daily activities appeared to be more beneficial than non-functional exercises. These results concur with previously published  studies, and evidence-based guidelines.

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All this public health activity must be underpinned by high quality data about musculoskeletal health.